A systematic review and novel classification of listing tools to improve medication in older people

Abstract

Purpose

Suboptimal drugs therapy is a threat to older people, and listing tools providing guidance are developed to address this problem.

Methods

A systematic review was performed to identify and analyze such tools published until February 2018. A novel categorization was developed to separate patient-in-focus listing approaches (PILA) providing disease-related positive and negative guidance from drug-oriented, mostly negative listing approaches (DOLA, DOLA+: with disease specification).

Results

In total, 76 tools were identified; only 9 were classified as PILA, 26 as DOLA, and 38 as DOLA+. Three DOLA(+) only address dementia. Most tools were developed in Europe or the USA and address community-dwellers. Thirty-two utilized a Delphi process, and only 10 provide a scoring system. Twenty tools utilize a questionnaire but no structured guidance or answers. Importantly, only 12 interventional clinical trials were identified reporting not only medication quality measures, but also clinical endpoints (e.g. falls, adverse drug reactions, hospitalization). For PILA, 4 trials showed positive, one negative clinical effects of a controlled intervention, for DOLA(+) 1 was positive, 7 negative (Fisher’s exact test p < 0.05).

Discussion

An abundance of listing tools has been created. DOLAs that may be applied without intricate patient knowledge prevail over PILAs by sevenfold; unfortunately their clinical validation seems to be far less successful than that of patient-initiated approaches.

Conclusion

Drug therapy in older people has to be tailored to their individual, very divergent needs; tools requiring detailed medical knowledge about the patient as the starting point for medication optimization provide the best support.

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Correspondence to Martin Wehling.

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Conflict of interest

M.W. was employed by AstraZeneca R&D, Mölndal, as director of discovery medicine (=translational medicine) from 2003 to 2006, while on sabbatical leave from his professorship at the University of Heidelberg. Since returning to this position in January 2007, he has received lecturing and consulting fees from Sanofi-Aventis, Bayer, Berlin-Chemie, Boehringer-Ingelheim, Aspen, Novartis, Takeda, Roche, Pfizer, Bristol-Myers, Daichii-Sankyo, Lilly, Otsuka, Novo-Nordisk, Shire, and LEO Pharma. In addition, the FORTA classification was developed by M.W.

F.P. and J.K. declare no conflicts of interest.

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Pazan, F., Kather, J. & Wehling, M. A systematic review and novel classification of listing tools to improve medication in older people. Eur J Clin Pharmacol 75, 619–625 (2019). https://doi.org/10.1007/s00228-019-02634-z

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Keywords

  • Polypharmacy
  • Listing approaches
  • Patient-in-focus tools
  • Drug-oriented tools
  • Clinical endpoints